 |
Police Chief June 1996 By Lieutenant Alan W. Benner, Ph.D., Department Psychologist, San Francisco Police Department and S. Marshall Isaacs, M.D., San Francisco Department of Health, Paramedic Division, San Francisco, California Problem 1: "Excited delirium" is not a recognized medical or psychiatric condition. However, with various media citing this descriptive phrase as a cause of death, street police officers find themselves held to a higher level of diagnostic acuity and standard of care than can be expected within their scope of responsibility, equipment and training. Problem 2: Well-meaning police departments are unintentionally creating a potentially libelous situation by recognizing "excited delirium" as a medical condition with "symptoms" that include commonly encountered street behaviors, and mandating that the condition be treated as a medical emergency. The Problem Excited delirium was originally a descriptive phrase coined by medical researchers to describe the extreme end of a continuum of drug abuse effects. Unfortunately, the professional literature, departmental training bulletins and—in many cases—agencies' general orders have expanded this descriptive phrase to a symptom of "life-threatening" linkage, effectively changing the phrase from a descriptive to a prescriptive medical mandate. When disconnected from the precursive drug phrase (such as "cocaine induced excited delirium"), the term "excited delirium" takes on the connotation of a recognized medical or psychiatric condition. It must be emphasized that excited delirium is neither a medical nor a psychiatric condition. It is a term used to describe the manifestations of extreme drug abuse. The Situation Over the past decade, increased attention has been paid to the sudden and seemingly inexplicable deaths of some subjects being held in police custody. In most of these cases, the force required to subdue the suspect was not sufficient to cause death. Medical authorities have typically had extreme difficulty in identifying the cause of death. A not-uncommon cause of sudden death in police custody is cocaine toxicity, a phenomenon noted by Drs. Mittleman and Wetli in the late 1980s. Cocaine is an agent that stimulates both the central nervous and the cardiovascular systems. Pharmacologically, cocaine constricts blood vessels, elevates the heart rate, raises blood pressure and increases body temperature. Such effects have produced lethal physiologic catastrophes in individuals without underlying preexisting anatomic disease(s). Mittleman and Wetli noted that the medical literature clearly documents cocaine-induced vasoconstriction, vasospasm and hypertension that have resulted in spontaneous intracranial hemorrhage and infarcts of the cerebrum (i.e. strokes), kidney and intestinal tracts. Cocaine may also be the cause of death in cardiovascular incidents in which there is no anatomic abnormality. Likewise, these effects can substantially compromise an already diseased heart or vascular system, potentially resulting in fatalities. Cocaine toxicity leading to death can exist in the drug abuser regardless of the actions taken by the police. Researchers found that cocaine-related emergencies in California climbed from 3,688 in 1985 to 10,660 in 1988. Although such emergencies dropped to 7,545 in 1990, the decrease lasted only a year. Since then, the numbers have climbed annually, reaching a record high of 13,496 in 1994. Similarly, amphetamine morbidity has taken on epidemic proportions. In 10 years, amphetamine-related emergency admissions in California increased by 366 percent, from 1,466 in 1984 to 6,834 in 1993. This increase in drug-related emergencies means that there will be an increased need for the police to handle such incidents, and probably an increase in sudden in custody deaths. The News Media In-custody death cases draw a great deal of attention from the news media and the community. After all, once a person is in police custody, all due care must be exercised to ensure his safety and medical well-being. An in-custody death may very well create an environment of suspicion concerning the propriety of the police action—even in communities where the police enjoy strong community support. "Police Probe of Suspect's Death Called a Cover-up" shouts the headline of an article in the San Francisco Chronicle. This article is one of a series on the in-custody death of a subject arrested on suspicion of burglary. Irrational and violently resistive, the subject had to be sprayed with Oleoresin capsicum (OC or pepper spray) before he could be subdued. After being transported to the district police station, he stopped breathing and died, despite attempts to revive him. According to the newspaper report, the medical examiner had not announced formally what killed the subject, but that ". . . it was either 'excited delirium'—a mental condition that can cause a heart attack—or the cramped position officers placed him in inside the police van, or a combination of these two causes." Three days prior to this "in-custody death," an individual who was irrational and violently resistive was rushed to San Francisco General Hospitals Strapped to a hospital gurney, he was still resisting violently when he suddenly succumbed. Although taken directly into medical emergency treatment, he died three days later. Both subjects were found to be suffering from drug toxicity, and both were going to die, regardless of any actions taken by the police or the medical team. Mittleman and Wetli noted that it is impossible to ascertain an individual minimal lethal dose of cocaine since fatalities have been associated with a wide range of concentrations. For example, the sudden occurrence of seizures and death has been documented in recreational users who chronically use even small amounts of cocaine. This phenomenon is apparently the result of a kindling effect—a reverse tolerance whereby the brain's sensitivity to cocaine is increased and its seizure threshold lowered. Fishbein and Pease noted that such potentially lethal seizures may occur any timed Exacerbating the Problem When the references to excited delirium contained in professional literature, departmental training bulletins and general orders are disconnected from the precursive drug phrase, there are two significant ramifications: (1) the more frequently the term "excited delirium" appears outside of the drug context, the more often it will be cited as a recognized medical or psychiatric condition; and (2) this then could provide the basis for a case of legal negligence if a standard of care is not provided to a person who dies while in custody and who has exhibited one or more of the published symptoms attributed to "excited delirium." These symptoms include:
Many of the people arrested daily will exhibit these characteristics, and none will have life-threatening symptoms. Think about this—how many people arrested by your officers are shouting and behaving violently toward others? How many are exhibiting bizarre behavior? Should all of these arrested subjects be taken to the hospital to receive a toxicology screen for drugs and have their pulse, temperature and blood pressure checked? The basic problem is that these symptoms are not specific enough to identify a medical emergency. In everyday situations, aggressive subjects are arrested, quieted down and transported to detainment facilities—most of them, without developing any medical problems. Addressing the Issue The issues surrounding the widespread use of the term "excited delirium" were discussed during the 102nd Annual IACP Conference held in Miami, Florida, October 14-19,1995. At the conclusion of these discussions, the IACP Police Psychological Services Section passed a motion: Police officials are encouraged to review their current policies and general orders, and re-consider the use of the phrase "excited delirium." Officials are also encouraged to visit their medical examiners and discuss the concerns raised by the use of descriptive terms in official medical reports describing the cause of death, especially in cases of in-custody deaths. It is hoped that in the future, medical researchers will be able to articulate with specificity the symptoms of persons suffering from drug-induced, life-threatening phenomena. For now, the state of knowledge is such that the medical profession may not always be able to treat the problem and save the life in a hospital. Obviously, then, police officers on the street should not be held accountable for failing to prevent drug users from killing themselves. That responsibility belongs to the users alone.
|
